Extended phenotype and clinical subgroups in unilateral Meniere disease: A cross-sectional study with cluster analysis.

OBJECTIVES: To define clinical subgroups by cluster analysis in patients with unilateral Meniere disease (MD) and to compare them with the clinical subgroups found in bilateral MD. DESIGN: A cross-sectional study with a two-step cluster analysis. SETTINGS: A tertiary referral multicenter study. PARTICIPANTS: Nine hundred and eighty-eight adult patients with unilateral MD. MAIN OUTCOME MEASURES: best predictors to define clinical subgroups with potential different aetiologies. RESULTS: We established five clusters in unilateral MD. Group 1 is the most frequently found, includes 53% of patients, and it is defined as the sporadic, classic MD without migraine and without autoimmune disorder (AD). Group 2 is found in 8% of patients, and it is defined by hearing loss, which antedates the vertigo episodes by months or years (delayed MD), without migraine or AD in most of cases. Group 3 involves 13% of patients, and it is considered familial MD, while group 4, which includes 15% of patients, is linked to the presence of migraine in all cases. Group 5 is found in 11% of patients and is defined by a comorbid AD. We found significant differences in the distribution of AD in clusters 3, 4 and 5 between patients with uni- and bilateral MD. CONCLUSIONS: Cluster analysis defines clinical subgroups in MD, and it extends the phenotype beyond audiovestibular symptoms. This classification will help to improve the phenotyping in MD and facilitate the selection of patients for randomised clinical trials.

Adherence of older people with instability in vestibular rehabilitation programmes: prediction criteria.

OBJECTIVE: To determine whether demographic characteristics or balance examination findings can predict the adherence of older people with instability to a vestibular rehabilitation programme. METHODS: A prospective case-control study was conducted of 120 patients aged 65 years or more (mean age, 77.3 ± 6.33 years). Two groups were classified according to patients' adherence with the follow-up post-rehabilitation protocol. Analysed variables included: age, sex, body mass index, Timed Up and Go test findings, computerised dynamic posturography, Dizziness Handicap Inventory scores and Short Falls Efficacy Scale - International questionnaire results, number of falls, and type of vestibular rehabilitation. RESULTS: Two groups were established: adherents (99 individuals) and non-adherents (21 individuals). There were differences between the groups regarding: sex (female-to-male ratio of 4.8:1 in adherents and 1.63:1 in non-adherents), age (higher in non-adherents) and voluntary movement posturographic test results (non-adherents had poorer scores). CONCLUSION: The patients most likely to abandon a vestibular rehabilitation programme are very elderly males with low scores for centre of gravity balancing and limits of stability.

What is the optimal number of treatment sessions of vestibular rehabilitation?

Vestibular rehabilitation is effective and safe in patients with instability. However, there is insufficient evidence for distinguishing between efficacies of different dosage of therapies. Therefore, the aim of the present study was to verify whether there were differences between two computerised dynamic posturography (CDP) therapies of different numbers of sessions, in order to establish the optimal strategy. We conducted a prospective, comparative study of two different dosage of CDP therapy (a 5-session group and another of 10-session group) in patients with instability due to chronic unilateral peripheral vestibular disorder. We used balanced block randomisation to include 13 patients in each group. Improvement was assessed using the Dizziness Handicap Inventory and the CDP with the sensorial organisation test (SOT) and limits of stability (LOS). We found a statistically significant improvement in both groups in composite score, visual and vestibular input (SOT); and in reaction time, distance and directional control (LOS). If we compare the groups regarding these improvements, we found that 10-session group showed a greater benefit in distance covered and directional control of LOS. Since significant improvement is obtained with only five sessions, we believe this to be the optimal number of treatment sessions for most patients with chronic unilateral peripheral vestibular disorder. Nevertheless, those patients with more reduced limits of stability, and consequently greater likelihood of falling as a result of their diminished base of support, are candidates for rehabilitation protocols with a greater number of sessions.

Familial clustering and genetic heterogeneity in Meniere's disease.

The aims of this study were to estimate the prevalence of familial cases in patients with Meniere's disease (MD) and to identify clinical differences between sporadic and familial MD. We recruited 1375 patients with definite MD according to the American Academy of Otolaryngology-Head and Neck Surgery criteria, obtaining the familial history of hearing loss or episodic vertigo by direct interview or a postal survey in 1245 cases in a multicenter study. Familial clustering was estimated by the recurrence risk ratio in siblings (λs ) and offspring (λo ) using intermediate and high prevalence values for MD in European population. A total of 431 patients (34%) reported a familial history of hearing loss or recurrent vertigo and 133 patients had a relative with possible MD. After clinical reevaluation, 93 relatives in 76 families were diagnosed of definite MD (8.4%), including three pairs of monozygotic twins. λs and λo were 16-48 and 4-12, respectively. We observed genetic heterogeneity, but most families had an autosomal dominant inheritance with anticipation. No clinical differences were found between sporadic and familial MD, except for an early onset in familial cases. We may conclude that MD has a strong familial aggregation and that sporadic and familial MDs are clinically identical.

Revised criteria for suspicion of non-benign positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is the most commonly diagnosed vestibular vertigo. BPPV can be diagnosed by clinical examination and its treatment is based on particle repositioning manoeuvres, and specialized equipment is not required. Therefore, most patients could be diagnosed and treated by their general practitioner. Unfortunately, not all positional vertigos are benign. Symptoms similar to those of BPPV can be caused by diseases that affect the central nervous system. It must be possible to define criteria that allow us to suspect, in a patient with symptoms of positional vertigo, the possibility of a cerebral origin ('non-benign PV'). Requests for magnetic resonance imaging must be justified by the fulfillment of these criteria. That is especially relevant in primary care, because these criteria should make possible to distinguish between patients with positional vertigo that could be treated by general practitioner and patients that need to be directed to especialized units. We propose the following revised criteria for suspected non-benign PV: (i) association with signs or symptoms of neurological disorder, (ii) nystagmus without dizziness in positional diagnostic tests, (iii) atypical nystagmus direction, (iv) poor response to therapeutic manoeuvres and (v) recurrence (confirmed by positional tests) on at least three occasions.

Benign paroxysmal positional vertigo of the posterior semicircular canal: efficacy of Santiago treatment protocol, long-term follow up and analysis of recurrence.

OBJECTIVES: To evaluate the efficacy of the Santiago treatment protocol for benign paroxysmal positional vertigo of the posterior semicircular canal, to analyse recurrence and to establish prognostic factors. MATERIAL AND METHODS: Four hundred and twelve patients with unilateral benign paroxysmal positional vertigo of the posterior semicircular canal were treated with the Semont manoeuvre and, if symptoms did not resolve, successive application of three Epley manoeuvres plus Brandt-Daroff exercises. RESULTS: Symptoms resolved in 404 patients (98.1 per cent); a single Semont manoeuvre was sufficient in 334 (81.2 per cent). Aetiology had no impact on resolution of symptoms or number of manoeuvres required. The estimated likelihood of recurrence was 14 per cent in the first year and 27 per cent after 10 years. The only factor indicating a worse prognosis was recurrence. CONCLUSION: In unilateral benign paroxysmal positional vertigo of the posterior semicircular canal, the above treatment protocol cured 98 per cent of patients. More than half of recurrences occurred in the first year. None of the analysed factors increased the likelihood of recurrence.

[Rehabilitation treatment of the balance: design of a general protocol with dynamic computerized posturography]. / Tratamiento rehabilitador de los trastornos del equilibrio. Diseño de un protocolo general con la posturografía dinámica computerizada.

The dynamic posturography (PD) is an amply diffused method for the study of balance. Its principal utility is the design of therapeutic strategies based on the vestibular rehabilitation. In determined patients and with the help of other elements of rehabilitation the PD favour the compensation of the degradation ofthe secondary balance to determinated pathologic entities that affect the vestibular peripheric or central system. Normally individualized strategies for each patient are employed and although this is the more correct, we consider necessary to propose global mesures that facilitate the rehabilitation program and the comparison of the results of different authors.

Tratamiento rehabilitador de los trastornos del equilibrio. Diseño de un protocolo general con la posturografía dinámica computerizada / Rehabilitation treatment of the balance: design of a general protocol with dynamic computerized posturography

La posturografía dinámica (PD) es un método ampliamente difundido para el estudio del equilibrio. Su principal utilidad es el diseño de estrategias terapéuticas basadas en la rehabilitación vestibular. En determinados pacientes y con apoyo de otros elementos de rehabilitación la PD favorece la compensación del deterioro secundario a determinadas entidades patológicas que afectan al sistema vestibular periférico o central. Normalmente se emplean estrategias individualizadas por cada paciente, y aunque esto es lo más correcto, consideramos necesario proponer unas pautas globales que faciliten la programación de la rehabilitación y la comparación de los resultados obtenidos por distintos autores

The dynamic posturography (PD) is an amply diffused method for the study of balance. Its principal utility is the design of therapeutic strategies based on the vestibular rehabilitation. In determined patients and with the help of other elements of rehabilitation the PD favour the compensation of the degradation of the secondary balance to determinated pathologic entities that affect the vestibular peripheric or central system. Normally individualized strategies for each patient are employed and although this is the more correct, we consider necessary to propose global measures that facilitate the rehabilitation program and the comparison of the results of different authors

[Pleomorphic adenoma of the tongue base. A new case of big size]. / Adenoma pleomorfo de base de lengua. Un nuevo caso de gran tamaño.

The pleomorphe adenomas (PA) of the tongue base are rare (there are only 6 cases published until now) We present one case of a male 42 years old with a PA of the tongue base very big but with few symptoms. The FNAB and MRI were the key for the diagnosis and therapy. The treatment was surgical with a trans oral resection. The patient is free of tumor after seven years.

Adenoma pleomorfo de base de lengua. Un nuevo caso de gran tamaño / Pleomorphe adenoma of the tongue base. A new case of big size

Los adenomas pleomorfos (AP) localizados en la base de lengua, constituyen un hallazgo inusual (sólo han sido publicados seis casos hasta la fecha). El presente art´ciulo presenta el caso de un varón de 42 años que presentó un AP de base de lengua muy voluminoso aunque paucisintomático. La PAAF y la RM fueron determinatnes en el diagnóstico y plan terapéutico. El tratamiento fue quirúrgico mediante resección transoral. El paciente está libre de tumor después de siete años (AU)

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[Computerized analysis of craniography: new limits of the norm for static and dynamic forms]. / Análisis computerizado de la craneocorpografía: nuevos límites de normalidad para sus formas estática y dinámica.

Literature about normal parameters of Craniocorpography (CCG) is scant and poorly documented. Its results are variable according to the series. Our aim is to reach a criteria of normality for CCG in our reference population. We have prospectively made Romberg and Unterberger tests to 72 healthy volunteers (mean age 34.7 years old, SD 17.07, 55.6% men) using a computerized method of measurement and making its estimation by means of a statistical model widely accepted. All the studied variables observe the conditions of Gaussian distribution. The normal limits for lateral and antero-posterior oscillation were 9 centimeters, 12 centimeters for lateral sway and 59 degrees to the right and 46 degrees to the left for angular deviation. The computerized method of analysis has facilitated the detection of the limits of the light tracings, which together with the careful design of our study guarantees the validity of the results.

Análisis computerizado de la craneocorpografía: nuevos límites de normalidad para sus formas estática y dinámica / Computerized analysis of craniocorpography: new normal parameters in static and dynamic tests

La literatura sobre rangos normales en craneocorpografía (CCG) es escasa y está, por lo general, mal documentada, informando resultados variables según las series. Nuestro objetivo es construir un criterio propio de normalidad CCG para nuestra población de referencia. Para ello realizamos, de forma prospectiva, las pruebas de Romberg y Unterberger a 72 voluntarios sanos (edad media 34,7 años; DS 17,07; 55,6 por ciento varones) utilizando un método de medida digitalizado y realizando su estimación mediante un modelo estadístico ampliamente aceptado. Todas las variables estudiadas cumplieron las condiciones de normalidad gaussiana. Los límites normales para la oscilación lateral y anteroposterior fueron 9 centímetros, para la amplitud de oscilación 12 centímetros y para la desviación angular 59º a la derecha y 46º a la izquierda. El método de análisis digitalizado empleado ha facilitado la detección de los límites de las huellas luminosas, lo que unido al cuidadoso diseño empleado apoya la validez de nuestros resultados (AU)

Literature about normal parameters of Craniocorpography (CCG) is scant and poorly documented. Its results are variable according to the series. Our aim is to reach a criteria of normality for CCG in our reference population. We have prospectively made Romberg and Unterberger tests to 72 healthy volunteers (mean age 34.7 years old, SD 17.07, 55.6% men) using a computerized method of measurement and making its estimation by means of a statistical model widely accepted. All the studied variables observe the conditions of Gaussian distribution. The normal limits for lateral and antero-posterior oscillation were 9 centimeters, 12 centimeters for lateral sway and 59 degrees to the right and 46 degrees to the left for angular deviation. The computerized method of analysis has facilitated the detection of the limits of the light tracings, which together with the careful design of our study guarantees the validity of the results (AU)

Neurinoma del acústico asintomático asociado con macroadenoma de hipófisis / Asymptomatic acoustic neuroma in association with pituitary macroadenoma

La utilización generalizada de la RM con gadolinio en la práctica médica de nuestros hospitales ha supuesto un aumento en el diagnóstico de neurinomas del acústico (NA) asintomáticos como hallazgo accidental. La asociación de tumores intracraneales de diferentes tipos celulares son extremadamente raros. Caso Clínico: Mujer de 23 años con ciclos menstruales irregulares y galactorrea de dos años de evolución. Una RM cerebral con gadolinio objetiva un macroadenoma hipofisario, acompañado de un NA de 1,4 cm. con extensión intracanalicular y cisternal. La paciente no presentaba síntomas o signos otológicos u otoneurológicos mediante anamnesis y exploración clínica. Los resultados obtenidos mediante audiometría tonal liminar, estudio del reflejo estapedial y electronistagmografía, fueron compatibles con la normalidad. Se realizó tratamiento con radiocirugía. Discusión: Revisamos la literatura sobre NA de presentación atípica, dando un énfasis particular sobre aquellos NA asintomáticos. Sólo hemos encontrado un caso de asociación entre adenomas hipofisarios y NA. Discutimos la prevalencia de los NA en la población general (AU)

The widespread use of gadolinium-enhanced MRI (Gd-MRI) in our hospitals has supposed an increase in detection of asymptomatic acoustic neuromas (AN) as incidental finding. Concurrent primary intracranial tumors of different cell types are extremely uncommon. CLINICAL CASE: A 23 year-old woman complained of irregular menstrual cycles and galactorrhea for two years. A Gd-MRI scan showed a pituitary macroadenoma and an AN of 1.4 cm. with intracanalicular and cisternal extension. The patient did not have any otologic or neuro-otologic symptoms or signs. Audiograms revealed bilateral normal hearing. The results of acoustic reflex test and electronystagmographic caloric tests were normal. The AN underwent radiosurgery treatment. DISCUSSION: The literature about atypical AN is reviewed, giving a particular concern on asymptomatic cases. We only have found one case of association between AN and pituitary adenoma. The real prevalence of AN in general population is discussed (AU)

[The usefulness of craniocorpography in the diagnosis of patients with dizziness and increasing muscle tension in the neck]. / La utilidad de la craneocorpografía en el diagnóstico de pacientes con alteraciones del equilibrio asociadas a contracturas de la musculatura cervical.

By the moment, craniocorpographic record of the Romberg test has been scarcely used in clinical practice. Since craniocorpography is a method for recording oscillations of the head and shoulders, it can show characteristic patterns in patients with vertigo caused by increased muscle tension in the neck. In order to confirm this hypothesis, a prospective comparative study was performed with 329 patients. They were included in three different groups: patients with cervical vertigo, patients with vestibular pathology and a healthy control group. Movements of the head (with static shoulders) are more usual in patients with cervical vertigo (67%) than in those with vestibular pathology (27%) and healthy subjects (31%). With regard to the kind of head oscillations, front-back flexions and oscillations in all directions were the most frequent (36% and 34%, respectively). Nevertheless, the only movements previously reported (cervical rotation or torsion) only were 3% of total head movements in our study. We concluded that static craniocorpography is an useful method in diagnosing vertigo secondary to increased muscle tension in the neck.

La utilidad de la craneocorpografía en el diagnóstico de pacientes con alteraciones del equilibrio asociadas a contracturas de la musculatura cervical / The usefulness of craniocorpography in diagnosing patients with dizziness and increasing muscle tension in the neck

El registro craneocorpográfico del test de Romberg apenas ha sido utilizado en la clínica hasta el momento. Puesto que registra los movimientos de la cabeza y de los hombros, puede presentar patrones característicos en pacientes con vértigo secundario a contractura de la musculatura cervical. Para tratar de confirmar esta hipótesis, se ha realizado un estudio prospectivo comparativo con un total de 329 sujetos, divididos en tres grupos: pacientes con vértigo cervical, con patología vestibular y un grupo control de personas normales. La presencia de desplazamientos cefálicos (movimientos de la cabeza, con hombros quietos) es más frecuente en los pacientes con vértigo cervical (67 por ciento) que en los afectados de patología vestibular (27 por ciento) y en los sujetos normales (31 por ciento). En cuanto al tipo de desplazamiento cefálico, los más frecuentes son las flexiones antero-posteriores (36 por ciento) y la oscilación en todos los planos (34 por ciento), mientras que los únicos movimientos de este tipo descritos previamente (la rotación o torsión cervical) no representan en nuestro estudio más que un 3 por ciento de los desplazamientos cefálicos. Concluimos que la craneocorpografía estática es una técnica útil como apoyo en el diagnóstico de los pacientes con vértigo secundario a contractura cervical muscular (AU)

By the moment, craniocorpographic record of the Romberg test has been scarcely used in clinical practice. Since craniocorpography is a method for recording oscillations of the head and shoulders, it can show characteristic patterns in patients with vertigo caused by increased muscle tension in the neck. In order to confirm this hypothesis, a prospective comparative study was performed with 329 patients. They were included in three different groups: patients with cervical vertigo, patients with vestibular pathology and a healthy control group. Movements of the head (with static shoulders) are more usual in patients with cervical vertigo (67%) than in those with vestibular pathology (27%) and healthy subjects (31%). With regard to the kind of head oscillations, front-back flexions and oscillations in all directions were the most frequent (36% and 34%, respectively). Nevertheless, the only movements previously reported (cervical rotation or torsion) only were 3% of total head movements in our study. We concluded that static craniocorpography is an useful method in diagnosing vertigo secondary to increased muscle tension in the neck (AU)

Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercises, Semont and Epley maneuver.

We performed a prospective study to evaluate the efficacy of three physical treatments for benign paroxysmal positional vertigo: Brandt & Daroff habituation exercises, the Semont manoevre (intended as a statoconia-detachment maneuver), and the Epley maneuver (intended as a statoconia-repositioning maneuver). A total of 106 BPPV patients were randomly assigned to one of the three treatment groups, and responses were evaluated one week, one month and three months after the initial treatment. At the one-week follow-up, similar cure rates were obtained with the Semont and Epley maneuver (74% and 71% respectively), both cure rates being significantly higher than that obtained with Brandt & Daroff exercises (24%). By the three-month follow-up, the cure rate obtained with the Epley maneuver was higher (93%) than that obtained with the Semont maneuver (77%), though both remained higher than that obtained with the Brandt & Daroff maneuver (62%). However, the proportion of initially responding patients showing subsequent relapse was lower among patients treated by the Semont maneuver than among patients treated by the Epley maneuver. In view of these findings, we propose a treatment algorithm for patients with BPPV.

[Asymptomatic acoustic neurinoma associated with hypophyseal macroadenoma]. / Neurinoma del acústico asintomático asociado con macroadenoma de hipófisis.

UNLABELLED: The widespread use of gadolinium-enhanced MRI (Gd-MRI) in our hospitals has supposed an increase in detection of asymptomatic acoustic neuromas (AN) as incidental finding. Concurrent primary intracranial tumors of different cell types are extremely uncommon. CLINICAL CASE: A 23 year-old woman complained of irregular menstrual cycles and galactorrhea for two years. A Gd-MRI scan showed a pituitary macroadenoma and an AN of 1.4 cm. with intracanalicular and cisternal extension. The patient did not have any otologic or neuro-otologic symptoms or signs. Audiograms revealed bilateral normal hearing. The results of acoustic reflex test and electronystagmographic caloric tests were normal. The AN underwent radiosurgery treatment. DISCUSSION: The literature about atypical AN is reviewed, giving a particular concern on asymptomatic cases. We only have found one case of association between AN and pituitary adenoma. The real prevalence of AN in general population is discussed.

[Epidemiologic and descriptive study covering one year of consultation in otoneurology department]. / Estudio epidemiológico descriptivo durante un año de una consulta de otoneurología.

The spread on Otoneurologic Units are increasing in number, because of the specific pathologic subjects it deals. But there are scanty epidemiologic studies on patients concurrent to these Unities. We report the data from a descriptive statistic pertaining to the Otoneurological Unit of our Hospital, in the wholly 1996. During this period of time 914 patients were attended, middle-aged 49.55, and the relation men/women being 0.61. The majority housewives, living in rural districts, prevailing the married women patients. The two ways of sanitary access more employed in so cases were: the otologist of the Social Security or reporting to the Urgency-Units of Hospitals. And the more complaining trouble was imbalance. Diagnosis more repeated was labyrinthine pathology due to ischemia and secondary vestibular conditions because cervical muscles contractures. We consider the profile of our patient group enhances the special risk in order to endure otoneurological pathology. And also we point out the fact that the most diagnosis are not related specially to vestibular pathology, but to other clinical entities not directly linked to an Otoneurologic dispensary.

[Dysfunction of the vocal cords simulating exercise-induced asthma]. / Disfunción de cuerdas vocales simulando asma inducida por el ejercicio.

Vocal cord dysfunction is a respiratory condition characterized by anomalous adduction of the vocal cords during inspiration, causing significant air flow limitation in the larynx. Few such cases have been described in which dysfunction is triggered by exercise. We report the case of a young women with severe dyspnea appearing as a result of physical activity. We first deal with issues of differential diagnosis in relation to several other diseases, particularly exercise-induced asthma and then discuss therapeutic approaches.

Sarcoma de Kaposi clásico en área O.R.L / Classical Kaposi Sarcoma in O.R.L

El sarcoma de Kaposi se trata de una neoplasia multifocal que surge de las células endoteliales vasculares. Se presenta un caso clínico de su forma clásica, localizado en la lengua y en extremidades inferiores. El tratamiento consistió en la inyección intralesional de interferón alfa subcutáneo, obteniéndose una mejoría clínica y morfológica de las lesiones (AU)

Kaposi's Sarcoma is a malignant neoplasty originated in vascular endothelial cells. Such medical case appears as its classical type located in the tongue and inferior limbs. The therapy consisted of intralesional injections of interferon alfa, leading into better clinic and macroscopic conditions of the injuries (AU)